Anand S. Patel MD*, Wyatt M. Tellis PhD, Mary Torosyan, David E. Avrin MD PhD, and Ronald L. Arenson, MD

UCSF Department of Radiology and Biomedical Imaging Laboratory for Radiological Informatics*Correspondence: anand.patel@ucsf.edu

The RSNA Image Share Network: Initial 12 Month Results from the

UCSF Pilot Site

Medicare expenditure on imaging has nearly doubled from $6.5B in the year 2000 to $11.7B in 2009.

At least 10-20% of these costs are due to duplicate exams, frequently due to inadequate access to prior exams when transferring patients between institutions.

In response the RSNA, in partnership with the NIBIB, launched the Image Share Network in 2009.

Introduction

Introduction

The Image Share Network is a secure cloud- based electronic personal health record (ePHR) where patients directly control, view, share, and manage their imaging exams.

The RSNA has partnered with 5 pilot sites in the USA to evaluate the Image Share Network: University of California, San Francisco (UCSF) Mount Sinai Medical Center Mayo Clinic (Rochester, MN) University of Chicago Medical Center University of Maryland Medical Center

Introduction

GOAL: to improve efficiency, safety, reduce repeat exams, and empower patients with direct control of their images and reports via a secure HIPAA compliant internet cloud-based ePHR.

As 1 of 5 national pilot sites, we present our experience at UCSF with patient enrollment, adoption, and patient/physician satisfaction.

Network Design Overview

The Image Share network has a hub and spoke design with a central “clearinghouse” through which all data are transferred.

Clearinghouse is hosted in a HIPAA-compliant, distributed data center with physical access controls.

Having a distributed data center provides business continuity by allowing the clearinghouse to continue operating in the event of a failure at one or more of the data center sites.

Network Design Overview

Network Security

Communication with the clearinghouse takes place over the internet and is secured using TLS 1.0 encryption. All nodes are authenticated through the exchange of TLS certificates.

Additional security is provided by a firewall with an access control list that permits only authorized IP addresses to connect.

Once data are at rest within the clearinghouse they are encrypted and automatically deleted after thirty days to minimize the chance of data theft.

Network Technical Details

To remain vendor agnostic, the network utilizes the IHE XDS-I.b standard for data exchange.

2 vendors currently provide PHR accounts to patients participating in the network Dell (InsiteOne) lifeIMAGE

Each site is interfaced to the clearinghouse via an “edge server” which acts as an XDS “document source.”

HL7 and DICOM are used to retrieve reports and images from the site’s RIS and PACS respectively.

Network Technical Details

Since the focus of XDS-I.b is the exchange of imaging data across affiliated enterprises, modifications were required for use in a consumer-oriented environment.

A unique, single use security token is used to identify submission sets within the network.

To retrieve content from the network, an ePHR must be able to reconstruct the token hash, the patient’s date of birth and a password known only to the patient.

By using this approach the network is able to abide by the XDS-I.b standard while providing an increased level of security by minimizing the exposure of PHI.

Methods

With IRB approval, Network enrollment began in Aug 2011 with patients coming to the department’s film library to obtain a CD of their exams.

During the first 10 months of the enrollment period (Aug 2011 – May 2012), our site enrolled patients as they contacted the film library for a copy of their images on a CD, either in person or over the phone.

Patients were educated about the system with a standard informational script communicated by the film library as well as formal brochures.

Methods Starting in Aug 2012, patients were also provided a

brief survey (2 pages for patient, 1 page for physician) to be completed after use of the system. Incentive $20 gift cards are provided to those patients

who mail back the survey.

Surveys gauge patients and physicians on: Perceived benefits/utility of patient-controlled ePHRs Importance of health record privacy Baseline computer, internet, and social media usage Satisfaction using the Image Share system (ease of

use, etc) Satisfaction with the Image Share system’s security Whether difficulty with access to CD or Image Share

system led to repeat imaging

Methods

Preliminary follow-up survey questions will be grouped and scored with mean response values based on the following scales: 1 most satisfied, 2 satisfied, 3 neutral, 4

unsatisfied, 5 very unsatisfied A score of 1 (daily) – 4 (never) is used to assess

patient and physician baseline computer/internet usage

Preliminary Results

During this initial period (Aug 2011 – May 2012) a total of only 90 patients (avg of 9 patients/mo), were enrolled.

When asked about the low enrollment rates, film library staff indicated that low enrollment patients were in a hurry, and not willing to spend time to go through the educational and consent process.

Starting in June 2012, the patient recruitment process was redesigned to enroll patients while they waited for their scans.

A recruitment coordinator was hired and dedicated to the task.

Overview of Modified Patient Recruitment Process

Patients checks in at Radiology reception area

Research coordinator introduces the RSNA Image Share Network

If patient wishes to enroll, research coordinator goes through the educational process prior to consent

If patient is not interested in the program, then patient awaits his or her scan

Once reports have been finalized, research coordinator sends requested images to the clearinghouse, emailing the patients with simple instructions for access

Patients access their images/reports, and request past and future studies with the capability to send the studies to any doctors, family, and friends, simply with a click of a button

Results

After starting the new process with a study coordinator, (3 months, Jun–Aug 2012), 357 patients were enrolled.

Monthly average of 119 patients Increase of 1222% over the previous 10 month

avg.

4 of the 5 pilot sites are currently enrolling patients Total of 1383 patients and 5807 exams.

447 patients enrolled at UCSF for a total of 2288 exams.

Results – Enrollment Overview Significant enrollment rate increase in May

2012 after hiring of a study coordinator.

Results – Patient Survey N = 66 total surveys returned as of Nov 1, 2012

Mean age 44 yrs (range 15 days to 87 years). Parents/legal guardians comprised 15% of enrollees

95%

5%

Frequency of general computer use

Daily

Weekly

Monthly

Never 55%27%

6%

13%

Frequency of internet use for social networking or online

purchasing

Results – Patient Survey

Perceived benefits/utility of patient-controlled ePHRs.

95% felt this was very important or important

Average satisfaction score 1.5 +/- 0.7 (1 most – 5 least satisfied)

2% stated they had repeat imaging because their physician had difficulty accessing it

85%

5% 11%Very satisfied or satisfied

Neutral

Unsatisfied or very unsatisfied

Results – Patient Survey Q’s “In general I am particularly

concerned about maintaining the privacy of my health records.” (1 strongly agree – 5 strongly disagree) Avg score 2.3 +/- 1.3

“I was comfortable with the privacy and security of how my medical images were transferred to my doctor or consultant.” (1 strongly agree – 5 strongly disagree) Avg score 1.6 +/- 0.8

62%22%

16% Strongly agree / agree

Neutral

Strongly disagree / disagree

87%

11%

2%

Strongly agree / agree

Neutral

Strongly disagree / disagree

Results – Patient Comments

“I love it!”

“Easy…helpful”

“The system works really well.”

“…pleased by the speed and grateful not to have to bring the image”

“This is really neat. I’ve always been curious about the images of my own organs.”

“I loved having the option to review my daughter’s scan with my husband who could not be at our appointment in SF as we live a couple hours away…”

“This was a great tool! I really appreciate the opportunity to take all the time I wanted to read the report and look at the images on my own.”

Results – Patient Comments

“had difficulty registering…”

“takes forever to download…”

“Felt process to access images online was not well defined. Need more detailed instructions on creating account and URL to use. Also, no instructions on what viewer to use for downloaded images. Took multiple attempts to download file…

“A link would be easier rather than having to highlight the address and open a new search”

“It was easy for me to access the images however I had a hard time accessing the report online.”

Results –Physician Survey

N = 34 total surveys returned

Average satisfaction score 1.8 +/- 1.3 (1 most – 5 least satisfied)

8% stated difficulty accessing CD exams led to repeat imaging study

12% stated difficulty accessing Image Share Network led to repeat imaging study

79%

21%Very satisfied or satisfied

Neutral

Results –Physician Survey Q’s “It was critically important

that I saw the medical image(s) in a short period of time.” (1 strongly agree – 5 strongly disagree) N = 33, avg score 1.2 +/- 0.6

“I am comfortable with the privacy and security of how this patient’s images were sent to me” (1 strongly agree – 5 strongly disagree) N = 27, avg score 1.4 +/- 0.7

94%

6%Strongly agree / agreeNeutralStrongly disagree / disagree

89%

11% Strongly agree / agreeNeutralStrongly disagree / disagree

Results – Physician Comments

“Dr. is at UCSF, so not applicable”

“I think this is great”

Discussion - Enrollment

The lengthy conversation required by the enrollment process proved to be an impediment for enrolling patients when they contacted the film library to request a CD copy of their images.

The modification to include a study coordinator helped increase numbers to their highest monthly total to date.

When patients were a “captive” audience in the waiting room they were far more willing to learn about the network.

Once they understood the process and its benefits, the majority of patients were enthusiastic to enroll.

Discussion – Patient Survey

85% of patients are satisfied or very satisfied with their experience using the RSNA Image Share Network. 11% nonetheless are unsatisfied or very unsatisfied,

perhaps due to online access/registration issues

87% either agreed or strongly agreed that they felt comfortable with the privacy/security of the system

38% of patients either disagree, strongly disagree, or are neutral that health record privacy is important This is perhaps higher than would be expected

Discussion – Physician Survey

79% of referring physicians are satisfied or very satisfied with their experience using the RSNA Image Share Network. None reported dissatisfaction

94% felt it was critically important to see medical images in a short time ~10% reported the necessity for repeat imaging

regardless of using CD or the Image Share Network

89% were comfortable with the privacy/security of the system None reported dissatisfaction

Discussion - Comments

Patients overall reported ease of use Certain patients voiced concerns that the online

registration process and system could be improved

Physician use is often difficult to gauge since most patients have a UCSF referring physician Already using the medical center’s own online

medical record and image viewer, thus obviating the need to use Image Share Network

Discussion - Survey

Potential considerations that could confound results: Most patients could be considered ‘computer literate’

based on their computer/internet usage Most patients believe ahead of time that there would be

significant utility of patient-controlled ePHRs Physician cohort may have been mostly homogenous

working at UCSF

Larger sample size needed to determine any relationships between the above patient characteristics

Focus on identifying and surveying physicians outside the UCSF network who do not already have access to the images via the UCSF medical record These physicians may be able to elucidate if the Image

Share system could obviate repeat exams

Further Studies

Further demographic and patient analysis will be performed to assess factors that may relate to adoption of the system, such as: Age Sex Distance patient resides from the medical center Type(s) of imaging exam patient underwent Chief diagnosis

Radiology department cost-analysis Are there savings from reductions in CD distribution?

Enrollment and surveying will continue through 2013

Cumulative results from all 5 pilot sites will be tabulated

Conclusion A cloud-based image exchange network is

technically feasible

Patients strongly feel that having a patient-controlled ePHR would be of benefit

Physicians strongly believe that viewing their patients images in a timely manner is critical

Patients and physicians are overall quite satisfied with their experience and the security of the RSNA Image Share Network

Patient education is critical to the adoption of the concept and the expansion of its use

References

1. Report to Congressional requesters: Medicare Part B imaging services—rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices. GAO-08-452. Washington, DC: Government Accountability Office, June 2008

2. Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007; 357:2277–2284

3. Brooks, L. (2009, November). RSNA Awarded Contract to Develop Medical Image Sharing Network. RSNA Press Release. Retrieved August 24, 2012, from http://www2.rsna.org/timssnet/media/pressreleases/pr_target.cfm?ID=460

4. ITI Planning and Technical committees. (2011, August 19). IT Infrastructure Technical Framework. IHE International, Inc. Retrieved August 28, 2012, from http://www.ihe.net/Technical_Framework/index.cfm#IT

Contact: anand.patel@ucsf.edu

https://www.rsna.org/Image_Share.aspx

http://www.radiology.ucsf.edu/

Thank You!